Provider Demographics
NPI:1366832909
Name:BROADNEY, DEWAYNE
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
Last Name:BROADNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 HANSKA WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2262
Mailing Address - Country:US
Mailing Address - Phone:919-825-8897
Mailing Address - Fax:
Practice Address - Street 1:9033 LAKE ROYALE
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-7208
Practice Address - Country:US
Practice Address - Phone:252-477-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS21099101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)